New Hope Counseling - Secure Client Area

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Terms and Policy

New Hope Counseling, PLLC Description of Services (Policies and Procedures)

Goals and Outcomes: Thank you for choosing New Hope
Counseling for your care and I look forward to helping you meet
your goals. Your goals are more likely to be met when you
understand the nature and limitations of counseling. Generally,
counseling is most useful in helping individuals help themselves
or improve their relationships by changing, feelings, thoughts,
and /or behaviors. You determine the nature and amount of change
you wish to make.

Benefits and Risks Most people experience improvement or
resolution to the concerns that brought them to counseling, but
of course, there are no guarantees: and there are some risks. For
example, counseling could open up new levels of awareness that
may cause discomfort.

Length of Therapy Many counseling issues can be resolved
in 12 or fewer sessions, however some issues require more
extensive care. Insurance companies require medical necessity for
counseling so your progress will be evaluated throughout
treatment and appropriate referrals for continued care after
service termination may be discussed. If two months have passed
since your last appointment or contact with me your case will be
closed. If you choose to return to services at any time in the
future your case can easily be reopened and you will be asked to
update your information

Confidentiality: I understand that the information you
share in counseling is personal. I will not release confidential
information without a written release of information form unless
such release is authorized or required by law. Your information
is protected but there are certain situations which I am required
by law to disclose the information. For example, I am a mandatory
reporter of child abuse/ neglect and intent to harm yourself or
others. By signing this description of Services you acknowledge
receipt of New Hope Notice of Privacy Practices. This document
describes your rights and my obligation regarding the use of your
private health information. Please be aware that insurance
companies require a mental health diagnosis and other identifying
information, including but not limited to, date of birth and
address.

Payment for Services: The fee for the initial 45 minute
assessment is billed to insurance for $150. Subsequent 45 minute
sessions are billed at $85.00. Please call your insurance company
in advance (benefits number or web site listed on your health
insurance card) for information about your mental health coverage
including if visits require pre- authorization, if there are a
limit to the number of visits and what your copay (your part of
the fee) will be. Please be prepared to pay your copay at each
visit. I accept cash credit or checks for payment. If you do not
have a mental health diagnosis or you are participating in life
coaching sessions insurance will not cover services and you may
choose to pay a discounted self pay fee. Consultation outside of
the office is billed at $85.00 per hour including travel time and
is not covered by insurance. Returned check fee is $40.

Appointment Cancellation: On occasion a situation may
arise which prevents you from keeping a scheduled counseling
appointment and I understand. As a courtesy please notify me at
least 24 hours in advance of your appointment if you cannot keep
it so I can offer it to another client. Except in emergency
situations, you may be personally charged a $30 cancellation/ no
show fee to offset the lost appointment time. Insurance companies
will not cover a no show fee. Emergency Phone Contact: Your phone
calls are received 24 hours a day by a confidential voicemail
system. Please leave a message and I will make every effort to
return your calls as soon as possible. I do not charge for brief
phone calls but do charge for ongoing or lengthy phone
communication. Please leave a message marked urgent if you are in
crisis and call 911 if you are in imminent danger of harming
yourself or others.

I have read the above information, and understand that I am
encouraged to ask questions and give input regarding the
counseling process at any time. If there is anything in this form
that I do not understand it is my responsibility to seek
clarification.

Electronic Signature of Client or Legal Guardian( Type Full Name )I have read and I agree to the New Hope Counseling, PLLC Description of Services (Policies and Procedures)

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU

CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The Health Insurance Portability and Accountability Act of 1996
("HIPPA") is a federal program that requires that all medical
records and other individually identifiable health information
used or disclosed by us, in any form, whether electronically, on
paper, or orally, are kept properly confidential. This Act gives
you, the patient, significant rights to understand and control
how your health information is used. HIPAA provides penalties for
covered entities that misuse personal health information.

As required by HIPAA, we have prepared this explanation of how we
are required to maintain the privacy of your health information
and how we many use and disclose your health information.

We may use and disclose your medical records only for each of the
following purposes: Treatment, payment, and health care
operations.

- Treatment means providing, coordinating, or managing
health care and related services by one or more health care
providers. An example of this would include a counseling session.

- Payment means such activities as obtaining reimbursement
for services, confirming coverage, billing or collection
activities, and utilization review. An example of this would be
sending a bill for your visit to your insurance company for
payment.

- Health care operations include the business aspects of
running our practice, such as conducting quality assessment and
improvement activities, auditing functions, cost-management
analysis, and customer service. An example would be an internal
quality assessment review.

We may also create and distribute de-identified health
information by removing all references to individually
identifiable information.

We may contact you to provide appointment reminders or
information about treatment alternatives or other health-related
benefits and services that may be of interest to you.

Any other uses and disclosures will be made only with your
written authorization. You may revoke such authorization in
writing and we are required to honor and abide by that written
request, except to the extent that we have already taken actions
relying on your authorization.

You have the following rights with respect to your protected
health information, which you can exercise by presenting a
written request to the Privacy Officer:

- The right to request restrictions on certain uses and
disclosures of protected health information, including those
related to disclosures to family members, other relatives, close
personal friends, or any other person identified by you. We are,
however, not required to agree to a requested restriction. If we
do agree to a restriction, we must abide by it unless you agree
in writing to remove it.

- The right to reasonable requests to receive confidential
communications of protected health information from us by
alternative means or at alternative locations.

- The right to inspect and copy your protected health
information.

- The right to amend your protected health information.

- The right to receive an accounting of disclosures of protected
health information.

- The right to obtain a paper copy of this notice from us upon
request.

We are required by law to maintain the privacy of your protected
health information and to provide you with notice of our legal
duties and privacy practices with respect to protected health
information.

This notice is effective as of March 23, 2009 and we are required
to abide by the terms of the Notice of Privacy Practices
currently in effect. We reserve the right to change the terms of
our Notice of Privacy Practices and to make the new notice
provisions effective for all protected health information that we
maintain. We will post and you may request a written copy of a
revised Notice of Privacy Practices from this office.

You have recourse if you feel that your privacy protections have
been violated. You have the right to file written complaint with
our office, or with the Department of Health and Human Services,
Office of Civil Rights, about violations of the provisions of
this notice or the policies and procedures of our office. We will
not retaliate against you for filing a complaint.

Please contact us for more information or to file a complaint:
The U.S. Department of Health and Human Services

Office of Civil Rights

200 Independence Avenue, S.W.

Washington, D.C. 20201

(202) 619-0257

Toll-free: 1-877-696-6775

Electronic Signature of Client or Legal Guardian( Type Full Name )I have read and I agree to the NOTICE OF PRIVACY PRACTICES